While a collaborative agreement is a critical part of opening a practice, too many nurse practitioners (NP) and physician associates (PA) consider it one of many tasks to check off. On the surface, these agreements seem like simple paperwork –– a signed document stating a physician’s agreement to collaborate or supervise.
However, the fine print and follow-through are what make these agreements compliant. Many providers learn the hard way that overlooking small steps can expose you to compliance violations, malpractice gaps or even license loss. People forget there’s a process: you have to submit the agreement and, in some states, get board approval. Signing it isn’t the finish line. It’s step one,” says Phoebe Gutierrez, who advises healthcare businesses and providers on operations and compliance.
After working with hundreds of clinicians, Gutierrez finds three common hidden risks that catch providers off guard and offers advice on how to avoid them.
Collaborative Agreement Risk #1: Failing to Submit to the State Board (NP & PA Compliance)
One of the most frequent mistakes NPs and PAs make with collaborative agreements is assuming you’re in the clear once you and your collaborating physician have signed it. In reality, many states require you to formally submit the document to the state board and even wait for approval before practicing.
Alabama, for example, has a lengthy approval process, while in Texas, you can use an online portal. In Florida, the physician must submit it, but in California, you just keep it on file.
Gutierrez lists the requirements for each state’s collaborative agreements on her website.
In many cases, providers don’t know what’s required of their collaborative agreements. “I’ve talked to providers in Alabama who never submitted anything. They thought they were compliant, but they were completely out of compliance,” says Gutierrez.
Collaborative Agreements for Multi-State NPs & PAs: Compliance Challenges
Multi-state providers are especially vulnerable. If you’re licensed in 15–20 states, it’s almost impossible to track each location’s compliance nuances without expert support or a detailed system. Assuming that one signed agreement covers all states where you practice is a dangerous shortcut.
Compact licenses don’t exempt you. Even if you’re practicing in a state under an interstate compact, you still have to follow that state’s submission rules. If you work for an employer, it’s typically their responsibility to submit the collaborative agreement, but you should still check that everything done on your behalf is compliant in the states where you work.
If you’re audited and can’t show proof of submission or approval, your collaborative agreement may be considered void. That can jeopardize your malpractice coverage and expose you to regulatory action.
Key takeaway: Always confirm whether your agreement has been submitted. Don’t assume your employer or telehealth platform has handled it.
Collaborative Agreement Risk #2: Why Agreements Don’t Transfer Across Clinics or Practices
Another common misconception is that one collaborative agreement can cover you in multiple locations or organizations. However, agreements are location-specific. If you have an agreement tied to one clinic, it doesn’t automatically apply if you also start working a few hours at another clinic. “Even if you use the same collaborating physician, you still need a separate agreement,” says Gutierrez.
Changing your scope of practice also requires updates. For example, if your agreement covers primary care, and you later expand into wound care or aesthetics, you’re technically practicing outside the scope of your collaborative agreement. You need to amend your agreement and resubmit to stay compliant.
In addition, particularly with the practice scope, your insurance may not protect you if you expand your services without informing your carrier. Malpractice carriers can (and do) reject claims if the care provided falls outside the practice, scope, or location listed in the agreement.
“Thinking you’re covered under an old agreement when you’re not can leave you completely unprotected in the event of a board complaint or lawsuit,” says Gutierrez.
Takeaway: Maintain separate agreements for each practice site or business entity, and amend them promptly whenever your services expand.
Collaborative Agreement Risk #3: Missing Clinical Protocols That Jeopardize NP & PA Practices
Finally, besides keeping you compliant, collaborative agreements exist for a reason. Done right, collaborative doctors can help you improve your delivery of care and contribute to the success of your practice. “Instead of treating collaborative agreements as boilerplate legal documents, what they really need are clear clinical protocols on how care is delivered,” says. Guitierrez.
Examples include:
- When to escalate processes in mental health, such as suicide ideation protocols
- Setting policies for prescribing medication or emergencies
- Defining scope in aesthetics
- Intake rules for services like IV therapy to identify who qualifies and who doesn’t
Without these protocols, your agreement is just a shell.
Related read: Beyond Compliance: Elevating the Collaborating Physician Role for Your Practice in 2025
Takeaway: Work with your collaborating physician to spell out the services you provide and how you provide them. Attach protocols as amendments and review and update the document annually or any time there’s a change in your practice.
Why Strong Documentation in Collaborative Agreements Protects NP & PA Licenses
Documentation is no doubt tedious, but it’s what keeps your license and malpractice coverage intact. “Providers want to provide care. They don’t like the documentation aspect. But that is what’s going to protect their license,” says Guitierrez.
If you’re practicing under a collaborative agreement—especially across multiple states or in telehealth—treat your agreements as living documents. Update them, submit them and keep detailed records. The paperwork may seem secondary to patient care, but the truth is that it’s your legal safety net.
Frequently Asked Questions
- Do nurse practitioners (NPs) and physician assistants (PAs) have to submit collaborative agreements to the state board? Yes. Many states require collaborative agreements to be formally submitted—and in some cases approved—before NPs and PAs can practice. Failure to submit can leave you out of compliance and put your license at risk.
- Can one collaborative agreement cover multiple practice locations or employers? No. Collaborative agreements are location-specific. If you work at more than one clinic or expand your scope of practice, you need a separate or updated agreement for each site to remain compliant and protected.
- Why are clinical protocols important in collaborative agreements? Clinical protocols define how care is delivered under a collaborative agreement, such as when to escalate care, prescribing policies, or intake rules. Without clear protocols, agreements may be considered weak, leaving NPs and PAs vulnerable to malpractice gaps and compliance issues.
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